Tag Archives: tuberculosis

In advance of the upcoming XIX International AIDS Conference, the International AIDS Society and the University of California, San Francisco, have issued the “Washington D.C. Declaration,” a nine-point action plan aimed at broadening global support for “Turning the Tide” of the AIDS epidemic.

1) An increase in targeted new investments;
2) Evidence-based HIV prevention, treatment, and care in accord with the human rights of those at greatest risk and in greatest need;
3) An end to stigma, discrimination, legal sanctions, and human rights abuses against those living with and at risk for HIV;
4) Marked increases in HIV testing, counseling, and linkages to services;
5) Treatment for all pregnant and nursing women living with HIV and an end to perinatal transmission;
6) Expanded access to antiretroviral treatment for all in need;
7) Identification, diagnosis, and treatment of tuberculosis;
8) Accelerated research on new tools for HIV prevention, treatment, vaccines, and a cure;
9) Mobilization and meaningful involvement of affected communities.

Turning the Tide is the theme of this year’s biennial conference, which will take place July 22-27 in Washington. It is expected to draw 25,000 attendees, including HIV professionals, activists, politicians, and celebrities. Sir Elton John will open the conference and Bill Clinton will close it. A large delegation of U.S. members of Congress will participate, and Bill Gates will moderate a session. An enormous “Global Village” outside the D.C. Convention Center will be open to the public. “If you haven’t been, it’s a conference like no other,” conference cochair Dr. Diane V. Havlir said at a press briefing.

The recent optimism regarding HIV/AIDS stems from major advances in knowledge regarding prevention of partner transmission with early patient treatment, pre-exposure prophylaxis, and male circumcision as HIV infection prevention (new data will be released at the meeting), all of which are viewed as breakthroughs in the fight against HIV/AIDS. “So we have now in our hands the tools. The question is how do we combine those tools together, and how do we roll them out,” said Dr. Havlir, professor of medicine at the University of California, San Francisco, and chief of the HIV/AIDS division at San Francisco General Hospital.

Dr. Diane V. Havlir / Photo by Miriam E. Tucker

Monday’s plenary session will include an address from Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases, on “Ending the HIV Epidemic: From Scientific Advances to Public Health Implementation.” Other plenary topics during the week will include viral eradication, vaccines, TB and HIV, and HIV/AIDS in specific populations including minorities, women, youth, and men who have sex with men. On Friday, there will be a plenary talk that may be of particular interest to the primary care community, “The Intersection of Noncommunicable Diseases and Aging in HIV.”

In Charles Dickens’ tale, A Christmas Carol, miserly Ebenezer Scrooge has a change of heart after visits from three very persuasive spirits. Among his charitable endeavors was to improve the health of Tiny Tim Cratchit, the crippled youngest son of Scrooge’s long-suffering clerk, Bob Cratchit.

Reproduced from a c.1870s photographer frontispiece to Charles Dicken's A Christmas Carol, courtesy of wikimedia commons

Tiny Tim’s condition is not fully described in the story, and has been the subject of speculation, since it was considered fatal (according to the Ghost of Christmas Present).

In the current issue of the Archives of Pediatrics and Adolescent Medicine, Dr. Russell W. Chesney of the University of Tennessee Health Science Center in Memphis offers a diagnosis, based in part on what we know about environmental factors during the time when the story was set (London, 1820-1843).

Dr. Chesney suggests that Tiny Tim had both rickets and tuberculosis. His odds of having rickets were fairly high, given the lack of sun exposure (due to coal-blackened skies and a tendency at the time for children of low-income families to work indoors in factories during daylight hours) and poor nutrition (due to Bob Cratchit’s meager salary). In addition, Dr. Chesney points out, pneumonia, upper respiratory infections, and TB are more common in those with vitamin D deficiency and rickets. Improving vitamin D status with better food (achieved when Bob Cratchit gets a long overdue raise in salary from Scrooge) would cure rickets and improve the TB, Dr. Chesney writes, so Scrooge’s generosity actually could make a difference in whether Tiny Tim lived or died.

“We are not told whether he was fully cured, but he definitely survived,” Dr. Chesney notes.

The moral of the story? Another victory for Vitamin D, and also, perhaps, for a good attitude. As Dickens said, “It is a fair, even-handed, noble adjustment of things, that while there is infection in disease and sorrow, there is nothing in the world so irresistibly contagious as laughter and good-humour.”

“The Archangel FDA shall fix upon the antibiotic pipeline a seal. And the seal shall be unbroken by any, be they monolithic pharmaceutical company or earnest researcher. And the pipeline shall narrow ever more, until I say unto you, it shall be easier for a camel to pass through the eye of a needle than for a new antibiotic to pass through the sealed pipeline.”

Normally a jovial and witty speaker, Dr. Theodore Rosen assumed a peculiar air during a talk at the summer meeting of the American Academy of Dermatology —a nearly indefinable mixture of gravitas and utter befuddlement. He agrees wholeheartedly with the new prudence of the Food and Drug Administration with regard to approving the vast majority of medications. Most of the time. But desperate times call for desperate measures.

And, according to Dr. Rosen, chief of the dermatology clinic at the Houston Veterans Administration and professor of dermatology at the Baylor College of Medicine, desperate times are upon us.

“We are being bombarded every year by increasingly resistant bacteria,” Dr. Rosen told me. “Some of these are relatively trivial, some are really bad—like MRSA—and some are wreaking havoc.”

So what’s the FDA doing about it? Not a whole lot, Dr. Rosen contends.

The agency’s exacting standards hamper research, he says. Noninferiority trials are standard for proving antibiotic efficacy, but there doesn’t seem to be any standard about just how noninferior the new drug has to be against its gold standard comparator. Is it 12%? 10%? Is it a moving target? Does it depend on the pair of drugs being compared?

There seem to be more questions than answers. But the result is that FDA has only approved one new antibiotic – televancin—since 2007. And there’s just no assurance that this will be sufficient. A quick Google search of resistant bacteria reads like a marquee of summer horror flicks (if you’re geeky enough).

Top billing has to go to NDM-1, New Delhi metallo-β-lactamase 1, which has conferred multidrug-resistance to Escherichia coli and Klebsiella pneumoniae in India, Pakistan, and the U.K. The bugs were highly resistant to all antibiotics except tigecycline and colistin.

Plagued by the Middle Ages? Yes, the disease that killed more than 200 million folks way back when is still alive and kicking – stronger than ever. Far from geezing, Yersina pestishas acquired a bagful of new tricks, including resistance to at least eight antimicrobials, among them streptomycin, tetracycline, and chloramphenicol. “Do we really want to let this genie out of the bag?” Dr. Rosen asked.

According to the World Health Organization, 2008 saw 9.5 million new tuberculosis cases and nearly 2 million deaths. About 150,000 deaths were due to multi-drug resistant strains; the bugs have been spotted in 58 countries.

In just one New York City hospital, 432 ceftazidime-resistant Klebsiella pneumoniae cases were found during a 19-month study period—17% of all the Klebsiella infections. The spike occurred in tandem with a ceftazidime war against multidrug resistant Acinetobater infections in the same institution.

Another jolly article confirms one of Dr. Rosen’s scariest points – not only are the stronger Klebsiellae adapting to our stronger antibiotics, they’re sharing that knowledge with their lowly E. coli cousins.

Slow as it may be to respond, this crisis is not solely of FDA’s making. Farmers, patients, and physicians each play key roles. Food animals are pumped full of antibiotics from conception until slaughter, providing a fast track for bacterial evolution. The fittest bugs survive and spread to farm workers, and even to the groundwater that sustains us all.

Patients remain notoriously unreliable when it comes to antibiotics, from nervous mamas demanding amoxicillin for baby’s every cough, to grownups who, feeling better after half a scrip, hoard the rest against a future bout of illness.

Docs are culpable as well, especially dermatologists Dr. Rosen said. “We treat acne and rosacea with antibiotics forever, instead of moving on as quickly as possible to topical therapies.”

FDA needs to quickly come to grips with the global rise of drug-resistant microbes, Dr. Rosen said. An overhaul of profit-driven animal husbandry is way overdue. On a more human scale, physicians need to keep pounding away at their patients to use antibiotics wisely and only as prescribed.

“And we need to listen to our own preaching, too,” he said. “It’s time to get real.”

On a global scale, noncommunicable diseases such as diabetes, cancer, and heart disease don’t just threaten health, but also development.

That’s how speakers framed the discussion at a World Health Organization panel on noncommunicable disease (NCD), held at the United Nations as a side session during the 43rd Session of the Commission on Population and Development (CPD).

Sir George Alleyne, director emeritus of the Pan American Health Organization, led off by calling NCDs a “major burden in terms of morbidity and mortality” in the developing world and a “neglected disease priority.”

Yet, 80% of NCDs can be controlled or prevented by reducing common risk factors such as tobacco use, unhealthful diets, and inactivity, measures addressed in the WHO’s 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases.

Dr. Rachel A. Nugent, deputy director for global health at the Center for Global Development, said that unlike infectious disease, which hits children and the elderly the hardest, NCDs primarily affect adults of working age. This in turn leads to reduced productivity and economic loss in developing nations.

A 2007 study found that a 10% increase in cardiovascular disease mortality among the working-age population decreases the per capita income growth rate by about 1 percentage point. Between 2006 and 2015, that loss is projected to total $84 billion (in U.S. dollars) worldwide.

“Even if health and social losses aren’t enough to compel us to action—and they are—the potential economic losses should move us to action,” Dr. Nugent said.

Dr. Gauden Galea of the WHO’s chronic disease division outlined the links between NCDs and infectious disease. For example, people with diabetes have a threefold increased risk for developing active tuberculosis, slightly more than the relative risk for active smokers.

According to a recent study, a 10% reduction in the death rate from NCDs would have a similar impact on progress toward TB eradication goals as would a rise in gross national product corresponding to at least a decade of growth in low-income countries.

Dr. Laurent Huber, director of the Framework Convention Alliance, an international antitobacco coalition, said his organization has joined forces with several international health groups and nongovernmental organizations to push for action on NCDs.

The coalition has two main priorities. One is inclusion of NCD indicators in the UN’s Millennium Development Goals (MDGs). Currently, the MDGs—the blueprint for world development that guides funding decisions—don’t even mention NCDs. An MDG Review Summit is slated for September 2010.

The other priority—also endorsed by the Commonwealth of Nations and the Caribbean Community—is a September 2011 UN General Assembly Special Session (UNGASS) on NCDs to raise political awareness of the issue, just as a 2001 UNGASS did for HIV/AIDS.

Dr. Alleyne, a Barbados-born physician who was knighted by Queen Elizabeth in 1990, sees the NCD UNGASS not just as a priority but a necessity. “This has to happen,” he told me when I spoke with him briefly after the session ended. “We need a push. This has to happen.”

from the American Academy of Pediatrics National Conference and Exhibition in Washington, D.C.

There’s no doubt that pediatricians have a lot of tasks to fit into a 10-minute healthy child visit. Not only do they have to give vaccinations — for which they often lose money — but these days they also have to invest time in educating parents about the safety and importance of those vaccines. You pediatricians out there certainly don’t get paid enough for this. Actually, you don’t get paid for this at all.

This afternoon, I sat through Dr. Gary Marshall’s talk on how to address parents’ concerns about vaccines. Dr. Marshall is the chief of the division of pediatric infectious diseases at the University of Louisville (Ky.). He discussed a number of reasons why vaccination safety is on parental radar these days, ranging from misinformed celebrities providing medical information to a general lack of understanding of vaccinology and the safety measures that are built into the vaccine development/licensure/marketing process.

Fundamentally though, we suffer from our tremendous success in virtually eradicating some truly terrible diseases. Without the specter of polio, tuberculosis, or measles in the news, the public has shifted from a fear of the diseases that these vaccines are intended to prevent to fear of the extremely rare side effects of the vaccines. As a result, pediatricians have to expend time they do not have on discussing the benefits of vaccinations and addressing parents’ fears. This is time that they could be devoting to more pressing and challenging health concerns for children, such as obesity, injury/violence prevention, and drug abuse.

This is what measles looks like. Image courtesy of NLM.

In the question and answer session, Dr. Marshall noted that it is ethical and permissible to discharge patients from a practice if their parents refuse vaccination. While this might ease the burden on the practice, is doing so really the best thing for the child? The implication is that, as long as a pediatrician is caring for the child, there is still the faint possibility that repeated discussion of vaccines with the parents might ultimately lead to the child being vaccinated.